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r! <br /> I•.. • SAN JOAQUIN COUNTY FILE COP Y <br /> tyr� ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> NIT IV <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 SITE UION <br /> Telephone:(209)468.3464 Fax:(209)468'433 Web:vmw s1oov.olalehd UNIT N <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELTS AND BORINGS USEO FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pemit to consh of WAW inataii the work deumbed. This application is made in compienca with San <br /> Joaquin County Development Tile,Chapter 9-1115.3,and the Standards of the Sen Joaquin Courtly EmIlronmental Heath Department. <br /> Stat.ocaton.2.HNb DaeiieA5 st. Cross sirm M,(f) (• am, bmvT City Mgwilua, zip 9533-4 APN ;Z41-53o '01 <br /> PoamfO° ! <br /> .rCostco WholLSAtI Arrau 11911 Lake 1��ve taty�ssa hRR0-4 phone <br /> Cbl Conhecw Viroil pK , Inc Address .16111 Challpnnt�hrlvC City I,tnr ord Oc3Q(?'405927phone 1125 $t'9 -070 <br /> consutanuaubagr KIPin{ I!l[32r Address 7 oda. SAt250__ Cty (ry/hn2 Lic Rhona 9H9 �2a _�ti/66 <br /> atlable Pert' ICI 2inQLId.Qr Address 'L Ari it-, rtw 25D city IIrvl✓nL zlp 9261Fr RhonegHR Z7,7 - r+66 <br /> GIS CoolWnaeee:X Y <br /> WNSTWeMNfa <br /> NEW WE N CPT OPROB HYDROPUNCH,I4WD-AUOE0.01NERI <br /> oRe 1 <br /> ❑WELL IDs <br /> C3 OTHER IDs <br /> TYPE&I OF WEUMPING INSTALLATION TWE CONSTRUCTION SPECT ICA'DONS <br /> _(]MONITORING 0 HOLLOW STEM CIA.OF BOREHOLE 2, ,5 O MULTIPLE CASINGS 0 MULTLLEVEL WELL CASING D14: A/A <br /> _0 DITRAnM VaparlWals, D HAMMERIORNEN CASMGTHICKNESS ..A(A�' qq��'��TYPE lM CAS7NG: O STEEL rj PVC D O <br /> T THEIR <br /> _O SOIL VAPOR PROBE O MLD ROTARY DEPOF GROUT SEAL TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> 1Q SOIL BORING GirpusH POM(GPI CPT) GROUT SEAL PUMPED:O Yr LTNs^MAMNI FRE ` ALL DEPTH IS se FTI <br /> n INRECTION Ri a w.mala Deets 0 HAND AUGER GROUT SPECIFICATIONS AHO.9,-� 1&{Vl Q_/1 <br /> _0 OTHER 0 OTHER: APPROX BORING DEPT- OI 1'� 0 BOLTED TRAFFIC BOX OR [3STOVE PIPE <br /> CONDUCTOR CASING UrNo 0 Yes:Crim Dia: Gamine Depth:_Soana Ow- <br /> COMMENTS, <br /> NOTE: OFFSITE WELLS 6 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DEBTRtJCTiON rEnao-rcHECX ALL THAT APPLY] <br /> _t OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: 0 PRESSURE GROUT TO DEPOT OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS HOSE RPE ❑MUSHROOM CAP AT 1:3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby C*rft tlaf I haw prepared this application and that Sha wort will M dopa N aecordMlp with San Joaquin County Ordinances,RUM*and <br /> Regulatlormh and at applkaMe AA <br /> Signed T'dWCompam T C9. IVP <br /> Print Name rfYUA IEUrt( Dela <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IVFILE SITE ADDRESS �AAJ f(--l.< S TAT r 71'(F.AN27-6- A <br /> WORK PLAN DATED RN<- IA 3 <br /> APPLICATION ACCEPTED BY .I .r'I D✓L Ki.t-^'\ DATE Is --7RtEA (G S• <br /> GROUT INSPECTION BY FINAL INSPECTION BY --eAME , <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTWCONDITIONS: <br /> ACCOUNTING ONLY: AID i FAC i <br /> PE CODES FEE INFO AMT REMITTED CHECK t RECV•D BY DATE SERVICE RO i INVOICE <br /> REQUEST PRi <br /> go 9125xC� s4e)3 Etfci q--z 3 sR4 6704O <br /> 2�to� 3J 5 3500 <br /> PR/ <br /> 3900 <br /> C47I_ WC _WAIVER 41r 057 LEITER OF AUTHORIZATION TO SIGN PERMIT / ENCROACHNEW DOCS <br />